Provider Demographics
NPI:1659140309
Name:FREDERICK, KELSI (CNP)
Entity type:Individual
Prefix:
First Name:KELSI
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KELSI
Other - Middle Name:JO
Other - Last Name:DAVISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3525 WESTERN GALES DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-9197
Mailing Address - Country:US
Mailing Address - Phone:918-803-2079
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS WAY # 653
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3500
Practice Address - Country:US
Practice Address - Phone:501-364-1100
Practice Address - Fax:501-364-4082
Is Sole Proprietor?:No
Enumeration Date:2023-12-21
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR121586363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics